Comparative Perspectives and Policy Learning in the World of Health Care

Abstract

The main point of this article is to explore the methodological questions raised by weaknesses in international comparative work in the field of health policy. The core question is how competent learning from one nation to another can take place. The article argues that there is a considerable gap between the promise and the actual performance of comparative policy studies. Misdescription and superficiality are all too common. Unwarranted inferences, rhetorical distortion, and caricatures, all show up too regularly in comparative health policy scholarship and debates. The article first describes the context of the health and welfare state reform debates during the past three decades. In almost all industrialized democracies, rising medical expenditures exacerbated fiscal concerns about the affordability of the mature welfare state. In reaction to pressure for policy change in health care, policy makers looked abroad for promising solutions to domestic problems. The following section takes up the topic of cross-national policy learning. Then, it critically reviews recent debates about health care reforms and addresses the purposes, promises and pitfalls of comparative study in health policy. The next section categorizes existing comparative health policy literature to highlight the character, possibilities and limits of such work. The concluding section returns to the basic theme: the real promise of comparative scholarship and the quite mixed performance to date.

Notes

1. This skeptical argument is advanced, with Anglo-American examples from medical care and welfare, by Marmor and Plowden (1991: 807–812). On the other hand, there is very rapid communication of scientific findings and claims, with journals and meetings regarded as the proper sites for evaluation. As yet, there is no journal in the political economy of medical care that has enough authority, audience, or acuteness to play the evaluative role assumed in the medical world by The New England Journal of Medicine, Lancet, BMJ, or JAMA.

2. Readers may be puzzled by our reluctance in this note to treat “reform” as the object of commentary. This paragraph's parade of substitutes – health policy, concerns, worries, and so on – reflects discomfort with the marketing connotations of the “reform” expression. That there are pressures for change are obvious and understanding them is part of our gathering's point, but reforming can obviously be a benefit, a burden, or beside the point.

3. In the 1990s work in English on health policy learning was for the most part concerned with a single topic, managed competition. This topic dominated reform discussion across countries between the mid-1980s and the mid-1990s. However, the focus was largely on the transatlantic relationship between the US and the UK (Klein 1991 and 1997; Marmor and Plowden 1991; Mechanic 1995; Marmor 1997; Marmor and Okma 1998; O'Neill 2000). There were complementary treatments of western Europe (Freeman 1999), southern Europe (Cabiedes and Guillen 2001) and New Zealand (Jacobs and Barnett 2000).

4. Technically, this is not strictly true of course, as is evident in the sickness fund financing of care in Germany, the Netherlands, and elsewhere. But, since mandatory contributions are close cousins of ‘taxes’, budget officials must obviously treat these outlays as constraints on direct tax increases. Moreover, the precise level of acceptable cost increases is a regulatory issue of great controversiality.

5. The bulk of this ideological struggle took place, of course, within national borders, free from the spread of “foreign” ideas. To the extent similar arguments arose cross-nationally, as Kieke Okma has noted, most represent “parallel development” (Report Four Country Conference 1995). But there are striking contemporary examples of the explicit international transfer and highlighting of welfare state commentary. Some of this takes place through think-tank networks; some takes place through media campaigns on behalf of particular figures; and, of course, some takes place through academic exchanges and official meetings. Charles Murray – the controversial author of Losing Ground (1984) and co-author of The Bell Curve (1994) – illustrates all three of these phenomena, as our British conferees can attest. The medium of transfer seems to have changed in the postwar period. Where the Beveridge Report would have been known to social policy elites very broadly, however much they used it, the modern form seems to be the long newspaper or magazine article and the media interview.

6. This is the argument developed in Marmor, Mashaw, and Harvey (1990: esp. ch.3). The wider scholarly literature on the subject is the focus of a review essay (Marmor 1993).

7. The turning to US health policy experience for lessons about cost control or insurance coverage seems particularly puzzling to American scholars preoccupied with health care problems at home.

8. Some readers have suggested this article is too pessimistic about the field of cross-national policy learning. And it is certainly true that some cross-national investigations have been enormously illuminating and helpful. For example, the 1964 Royal Commission on Health Services was an exemplary investigator of the experience of other countries. In the 1990s comparative policy investigations by Japanese and German analysts were important in nursing home reforms in both countries.

9. For an elaboration of this point, see Marmor (1994: ch.12). A particularly careful and extensive treatment of the North American experience is the review article by Evans, Barer, and Hertzman (1991).

10. The political fight over the Clinton health plan vividly illustrates these generalizations. The number of interest groups with a stake in the Clinton plan's fate – given the nearly $1 trillion medical economy – was enormous; there were more than 8,000 registered lobbyists alone in Washington and thousands more trying to influence the outcome under some other label. The estimates of expenditures on the battle are in the hundreds of millions; one trade association, The Pharmaceutical Manufacturer's Association, spent $7 million on “public relations” by 1993. The most noted effort was that of the Health Insurance Association of America, which produced the infamous Harry and Louise advertisements. Washington was awash in interest group activities during the health care reform battle of 1993 – 94, but the character, impact, and meaning of those activities are far from clear.

11. One of the Dutch policy commentators in a chapter dealing with cross-national perspectives on the Dutch welfare state and its health system strikingly illustrates how one can oddly justify not learning much from comparative policy studies. “Comparative studies”, he writes, “are generally backward looking, so don't always provide us with the right answers for the future” (personal interview 2004). The restrictive definition of the purpose of comparative inquiry – getting the “right answers” – limits greatly what this Dutch public servant would consider useful.

12. As Hacker (2002: 7) rightly points out, the “share of the US economy devoted to social welfare spending is not all that different from the corresponding proportion in even the most generous of European welfare states”. The “sources” of the spending – tax expenditures and employment-benefits especially – are what distinguishes the American case. The same myth of the “lean” American welfare state was the object of criticism in a book published a decade earlier (Marmor, Mashaw and Harvey 1990).

13. The 2000 WHO report seeks to rank health systems across the globe. The WHO posed good questions about how health systems work: are they fair, responsive to patient needs, efficient, and do they provide good quality health care. But it answered those questions without much attention to the difficulties of describing responsiveness or fairness or efficiency in some universalistic and reliable manner. What is more, the report used as partial evidence the opinions of WHO personnel to ‘verify’ what takes place in Australia, Oman, Turkmenistan, or Canada. Moreover, while the report claims to provide data in order to improve health systems across the globe, it is hard to see how a health minister of a country ranked, say, at place 125, has any stake to climb the ladder. Predictably, most of the uproar about the report was the battle between the countries that ranked high but not highest. Many journalists and members of parliament quoted the report as a critical comment on the failures of the national health system whereas, unsurprisingly, the French minister saw the number one ranking of his country (that in the end turned out to be based on a calculating error) as proof of the effectiveness of his policy. With comparisons like that, one can easily understand why some funders of research regard comparative policy studies as excuses for boondoggles. But that should not drive out the impulse for serious cross-national scholarship and learning.

14. For a retrospective appreciation of Anderson, see Freeman and Marmor (2003).

15. There is a rich scholarly disability literature, with a good deal of knowledgeable commentary on comparative policy developments. See especially Aarts and De Jong (2003).

16. Good examples are Freddi and Bjorkman's Controlling Medical Professionals (1989) and Ranade's Markets and Health Care (1998); another is White's Competing Solutions (1995), written at the Brookings Institution to draw lessons from OECD experience for the universal health insurance debate in the United States. Sometimes journals present work of this kind: see the case studies of priority setting in Health Policy (1999), for example, and the Journal of Health Politics, Policy and Law (2001) for international commentary.

17. A good example of this genre is the book edited by Bayer and Feldman (1999) on the politics of contaminated blood in Germany, France, Japan, Canada, Denmark, and the United States: Blood Feuds. The theme is taken up in Bovens, 't Hart and Peters's (2002) Success and Failure in Governance, which also looks at medical professions and health care reform.

18. For instance, Pierson (1994) compares retrenchment politics in Reagan's America and Thatcher's England; Immergut (1992) compares the disputes over national health insurance in France, Switzerland, and Sweden in the early part of the twentieth century; and Maioni (1998) the different paths to national health insurance taken in Canada and the United States. Moran (1999) assesses the political economy of health care in Britain, Germany and the United States, Freeman (2000) the politics of health care in five European countries.

Additional information

Notes on contributors

Ted Marmor

Ted Marmor teaches politics, law, and management at Yale University. His most recent book is Fads and Fashions in Medical Carre Policy and Management, 2004. Richard Freeman teaches government, health policy and political research at the University of Edinburgh, Scotland. He is author of The Politics of Health in Europe (Manchester UP, 2000) and co-editor of Social Policy in Germany (Harvester Wheatsheaf, 1994) and Welfare and Culture in Europe (Jessica Kingsley, 1999). He has held visiting fellowships at the Robert Schuman Centre, European University Institute, Florence and at the Institution for Social and Policy Studies, Yale University, and is currently research fellow at the Hanse Institute for Advanced Study, Bremen, where he is working on cross-national learning in health and public policy. Kieke Okma worked with the Dutch Government and as a policy adviser to the Dutch Ministry of Health before taking early retirement in 2004. She now works as an international consultant in health care, health finance and health law and is Visiting Professor at the Catholic University in Leuven, Belgium. Recent publications include papers and articles on health care and EU law, Information technology, consumer driven health care and other topics. The authors want to thank Avi Feller, our research assistant and Yale undergraduate, for his helpful assistance with this article.